Our responsibility must not stop here, however, and we must continually seek to improve our skills, both as practitioners and as a profession. We must adopt many of the principles in the general field known as "physical medicine" to add to our repertoire of treatment methods. The major approach of physiatry and other physical medicine disciplines is therapeutic exercise. If these principles are added to the empirical and anecdotal knowledge that is contained in the general practice of chiropractic health care, then a truly stronger concept of combined treatment will emerge.
The value of exercise prescription cannot be ignored in cases such as motor vehicle accidents, personal injury cases, and work-related injuries. These same principles of strengthening and rehabilitation apply to patients with difficulties not related to the above injuries. Chronic problems such as degenerative joint disease, myofascial pain syndromes, and other conditions respond well to a prescribed, partially monitored exercise program; the only limitations are physical ability and patient compliance.
Individual medical professions differ somewhat in their approach to musculoskeletal injuries in a variety of areas. However, with exercise prescription, everyone basically goes by the same rules. Physiatry and physical therapy use essentially the same methods as chiropractic and osteopathy, though the latter two have not used exercise as the first or second treatment of choice, as have the former two.
This article is intended to outline some basic ideas regarding exercise prescription and the chiropractic patient. If we expect third-party payers to reimburse us for this service, we need some standards and goals for patient management. The Mercy Guidelines have touched on this issue and some individuals have made some limited protocols, but more attention needs to be devoted to this vital part of chiropractic care.
In order to have clinical reasoning to support the treatment, we need to define what exercise does to the injured tissues, as well as to the patient as a whole. The main effects are as follows:
- Restoring strength, endurance, and bulk to detrained muscle groups. This is the fundamental basis of returning a patient back to prior functional capacity.
- Increased blood flow to injured tissues to quicken the onset of the healing process.
- Prevent formation of fibrinous adhesions with active muscle contraction and joint motion, and reduce them after their formation.
- Neuromuscular retraining, defined as moving a muscle against resistance to retrain neural pathways that have been previously inhibited by pain or immobilization of a motor unit. This prevents the entrenching of improper or nonoptimum neuromuscular patterns of movement that may later cause pain after a sudden uncoordinated movement. An example might be abnormal tightness in intrinsic muscles that can produce abnormal spinal motion.
- Restore aerobic capacity to preinjury levels if the patient's job or normal activities demand it. There are also some studies that show aerobic exercise alone has a significant effect of reducing low back pain.
- Restore the patient's confidence that they can perform normal tasks and use the injured region in a normal manner. This can minimize "functional overlay" and get the patient back to normal activities quicker. Exercise prescription can also be used to determine if functional overlay is present because the physician is directly observing the patient performing a number of revised or nonresisted movements, and can use this information for comparison of orthopedic testing and other objective findings.
- Pain reduction through the pain gate pathway and the release of endorphins and other neural active substances.
Once the decision has been made that the patient would benefit from exercise prescription, several things must be considered. If there is any doubt that the patient's injury or problem is not going to respond to the therapy, caution should be taken before embarking on a program. The following points must be considered when prescribing a treatment regimen that includes exercise:
- The physician must take into account patient compliance in considering exercise rehabilitation.
- The history of the case must support the use of exercise. A complete picture of the pathophysiology of the injury will allow for a more accurate program of exercise prescription.
- The following pathologies are often effectively treated with exercise rehabilitation: true sprains/strains; cervical acceleration-deceleration injuries; lumbosacral injuries including but not limited to: muscle spasms secondary to intrinsic muscle strain; capsular sprain; discogenic pain; and sclerotogenous pain. Upper extremity and lower extremity injuries also respond well, provided the exact pathophysiology is known. Any musculoskeletal soft tissue injury may be treated with exercise as it increases muscle, tendon, and fascial strength, as well as increasing the vascularity to the region and reducing fascial adhesion formation.
Some authors feel that the main use of exercise therapy is to strengthen the patient after a long period of inactivity or detraining. The exercise prescription program also shows the injured patients that they can exert themselves without injuring themselves further, which is often a problem after being told by their treating physician not to do things that hurt them. I believe that this is a factor, though definitely not the only factor in exercise therapy.
- Any exercise rehabilitation program should include a minimum of the following equipment/facilities:
- free weights with appropriate benches, including barbells and dumbbells;
- weight machines, preferably cable weight machines;
- aerobic exercise equipment including stationary bicycles, step machines, recumbent bicycles, treadmills and the like;
- swimming facilities, particularly for severely detrained patients who need to gain mobility and some initial aerobic capacity and strength;
- a matted floor, very useful in performing agility drills and exercises to retain synergistic muscles and muscle coordination, and for retraining a patient that has a neuropathic or proprioceptive loss (as seen with peripheral nerve damage or a sprained ankle, respectively).
Exercise prescription may also address mobility, strength, endurance, and cardiovascular deficits. The exercise must involve simulation of customary physical activities to restore task-specific endurance, coordination, and agility through strong neuromuscular inputs. Obviously, the exercises must be aimed at the specific functional units that have been injured and/or deconditioned.
Strength may be restored after an injury in a variety of modes. Isometric exercises may be the only type that can be performed during immobilization at the beginning. There are many drawbacks to this kind of exercise, however, including being the most fatiguing and the least effective. There is specificity of strength training to the length of the muscle fiber with a rapid decrease in efficiency at different joint angles or fiber lengths. There is also no agility gained by this form of exercise. However, it is good to start with.
Dynamic muscle training can be employed later. This obviously involves movement.
The modes of dynamic muscle training will be discussed in Part II in the April 23 issue.
Michael P. Thille, DC
Milwaukie, Oregon